How are health-related behaviours influenced by a diagnosis of pre-diabetes? A meta-narrative review

Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation

BACKGROUND

Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D).

METHODS

Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods.

RESULTS

People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness.

CONCLUSIONS

Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

Explaining the UK's 'high-risk' approach to type 2 diabetes prevention: findings from a qualitative interview study with policy-makers in England

OBJECTIVES

When seeking to prevent type 2 diabetes, a balance must be struck between individual approaches (focusing on people's behaviour 'choices') and population approaches (focusing on the environment in which those choices are made) to address the socioeconomic complexity of diabetes development. We sought to explore how this balance is negotiated in the accounts of policy-makers developing and enacting diabetes prevention policy.

METHODS

Twelve semistructured interviews were undertaken with nine UK policy-makers between 2018-2021. We explored their perspectives on disease prevention strategies and what influenced policy decision-making. Interviews were transcribed and analysed thematically using NVIVO. We used Shiffman's political priority framework to theorise why some diabetes prevention policy approaches gather political support while others do not.

RESULTS

The distribution of power and funding among relevant actors, and the way they exerted their power determined the dominant approach in diabetes prevention policy. As a result of this distribution, policy-makers framed their accounts of diabetes prevention policies in terms of individual behaviour change, monitoring personal quantitative markers but with limited ability to effect population-level approaches. Such an approach aligns with the current prevailing neoliberal political context, which focuses on individual lifestyle choices to prevent disease rather than on infrastructure measures to improve the environments and contexts within which those choices are made.

CONCLUSION

Within new local and national policy structures, there is an opportunity for collaborative working among the National Health Service, local governments and public health teams to balance the focus on disease prevention, addressing upstream drivers of ill health as well as targeting individuals with the highest risk of diabetes.

It is time for a more targeted approach to prediabetes in primary care in Aotearoa New Zealand

Type 2 diabetes (T2DM), its related morbidities and entrenched diabetes-related inequities pose significant challenges for health care delivery systems in Aotearoa New Zealand (NZ). Primary care services undertake the majority of diabetes prevention work by initially detecting and managing those with prediabetes. In this viewpoint, we present available NZ data to highlight NZ trends in prediabetes and consider the current NZ clinical guidelines and the prediabetes care pathway. Multiple areas for improvement are identified to optimise diabetes prevention, potentially reduce T2DM inequities, and sustain more effective prediabetes management in primary care in NZ.

How do UK general practice staff understand and manage pre-diabetes? A focus group study

Background

Preventing type 2 diabetes is a national priority; one aspect is the identification and active management of ‘prediabetes’ through lifestyle change.

Aim

To explore what primary care clinicians understood by ‘prediabetes’, how they communicated this diagnosis to people, how they delivered lifestyle advice, and their views on barriers to lifestyle change.

Design & setting

Three focus groups were undertaken with 25 individuals from primary care teams (GPs, nurses, and healthcare assistants) in Newham, a deprived and ethnically diverse part of London, UK.

Method

Recordings were transcribed verbatim and analysed thematically before integrating social and behavioural science theories.

Results

Focus groups participants described four main influences on their management of prediabetes in the consultation: social determinants, clinical aspects of diagnosis and management, patient motivation and behaviour change, and long-term care. Since most felt unable to address social determinants such as poverty, discussions with patients tended to focus on attempts to change individual behaviours and achieve particular numerical targets, with limited attention to the social context in which behaviours would play out.

Conclusion

Type two diabetes prevention efforts in general practice may fail to address the upstream causes of this disease. A narrow focus on numerical targets and decontextualised behaviours overlooks the social complexity of human behaviour and lifestyle choices. Within the consultation, the authors recommend that greater attention is paid to discussing the social context and meaning of particular behaviours. Beyond the consultation, collaboration between primary care clinicians, public health bodies, and local governments is required to address community-level constraints to behaviour change.

The process of health behaviour change following participation in a randomised controlled trial targeting prediabetes: A qualitative study

AIM

To explore how participating in a randomised controlled trial affected motivation, barriers and strategies in the process of health behaviour change among individuals with prediabetes.

METHODS

An extension to the PRE-D trial, a qualitative study investigated the efficacy of glucose-lowering interventions (metformin, dapagliflozin or exercise) compared with a control group among individuals with prediabetes and overweight/obesity. Data were collected through separate focus group interviews with participants using semi-structured interview guides inspired by health behaviour change theories. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis with an inductive-deductive approach.

RESULTS

Four interrelated themes were generated from interviews: (1) 'self-construction of prediabetes', on how participants understood the term 'prediabetes', (2) 'altered health image', on how participants' health perceptions were affected, (3) 'personal strategies for health behaviour change', on different ways to attempt to implement behaviour changes and (4) 'the process of health behaviour change', on how participants progressed and relapsed while trying to change behaviour. Themes relate to the health belief model, self-determination theory, self-efficacy and the trans-theoretical model of change. Participants shared their experiences and thoughts during interviews and inspired each other, which led some participants to develop a new perspective on prediabetes severity and increased their motivation for behaviour change.

CONCLUSIONS

How participants perceived and accepted, rejected or neglected prediabetes appeared to affect their health images and whether they realised a need for behaviour change. Their achievements during interventions, health literacy, self-efficacy and perceived support from their social networks, professionals and technological aids influenced the maintenance of health behaviour changes.

Facilitators and barriers for lifestyle change in people with prediabetes: a meta-synthesis of qualitative studies

BACKGROUND

The increasing prevalence of type 2 diabetes worldwide is a major global public health concern. Prediabetes is a reversible condition and is seen as the critical phase for the prevention of type 2 diabetes. The aim of this study is to identify and synthesize current evidence on the perceived barriers and facilitators of lifestyle change among people with prediabetes in terms of both initial change and lifestyle change maintenance.

METHODS

A systematic literature search in six bibliographic databases was conducted in April 2021. Potential studies were assessed for eligibility based on pre-set criteria. Quality appraisal was done on the included studies, and the thematic synthesis approach was applied to synthesize and analyse the data from the included studies.

RESULTS

Twenty primary studies were included, containing the experiences of 552 individuals. Thirteen studies reported participants perceived facilitators and barriers of lifestyle change when taking part in community-based lifestyle intervention programs, while seven studies reported on perceived facilitators and barriers of lifestyle change through consultations with health care professionals (no intervention involved). Three analytical themes illuminating perceived barriers and facilitators for lifestyle change were identified: 1) the individual's evaluation of the importance of initiating lifestyle change, 2) the second theme was strategies and coping mechanisms for maintaining lifestyle changes and 3) the last theme was the significance of supportive relations and environments in initiating and maintaining lifestyle change.

CONCLUSION

Awareness of prediabetes and the perception of its related risks affects the motivation for lifestyle change in people at risk of type 2 diabetes; but this does not necessarily lead to lifestyle changes. Facilitators and barriers of lifestyle change are found to be in a complex interplay within multiple ecological levels, including the interpersonal, intrapersonal, environmental and policy level. An integrated understanding and analysis of the perceived barriers and facilitators of lifestyle change might inform people with prediabetes, healthcare professionals, and policy makers in terms of the need for psychological, social, and environmental support for this population.

Developing a Behavior Change Framework for Pandemic Prevention and Control in Public Spaces in China

Preventive behavior, such as hand hygiene, facemask wearing, and social distancing, plays a vital role in containing the spread of viruses during pandemics. However, people in many parts of the world usually encounter difficulties adhering to this behavior due to various causes. Thus, this article aims to develop a research framework and propose design strategies to prompt individuals’ behavior change during pandemics. Initially, we integrated a literature review and a structured interview (n = 22) to ascertain the core factors impacting behavior change during pandemics. These factors were categorized into four aspects: perceptional factors (attitudes, subjective norms and perceived behavior control, risk perceptions); social factors (knowledge and information dissemination, governmental regulations); physical factors (tools and facilities and surveillance); and sociocultural factor (cultural contexts). Then, a theoretical framework with antecedents was developed to reveal behavior intention and formation process. After that, an empirical study was carried out to test the research framework through a questionnaire survey (n = 549). The research findings indicated that all derived factors could directly or indirectly affect individuals’ preventive behavior during pandemics. This article strives to provide valuable insights for different stakeholders when coping with pandemic situations.

The Adaptation of a Youth Diabetes Prevention Program for Aboriginal Children in Central Australia: Community Perspectives

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6–11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.

Could social prescribing contribute to type 2 diabetes prevention in people at high risk? Protocol for a realist, multilevel, mixed methods review and evaluation

INTRODUCTION

Social prescribing is an innovation being widely adopted within the UK National Health Service policy as a way of improving the management of people with long-term conditions, such as type 2 diabetes (T2D). It generally involves linking patients in primary care with non-medical community-based interventions. Despite widespread national support, evidence for the effectiveness of social prescribing is both insufficient and contested. In this study, we will investigate whether social prescribing can contribute to T2D prevention and, if so, when, how and in what circumstances it might best be introduced.

METHODS AND ANALYSIS

We will draw on realist evaluation to investigate the complex interpersonal, organisational, social and policy contexts in which social prescribing relevant to T2D prevention is implemented. We will set up a stakeholder group to advise us throughout the study, which will be conducted over three interconnected stages. In stage 1, we will undertake a realist review to synthesise the current evidence base for social prescribing. In stage 2, we will investigate how social prescribing relevant to people at high risk of T2D 'works' in a multiethnic, socioeconomically diverse community and any interactions with existing T2D prevention services using qualitative, quantitative and realist methods. In stage 3 and building on previous stages, we will synthesise a 'transferable framework' that will guide implementation and evaluation of social prescribing relevant to T2D prevention at scale.

ETHICS AND DISSEMINATION

National Health Service ethics approval has been granted (reference 20/LO/0713). This project will potentially inform the adaptation of social prescribing services to better meet the needs of people at high risk of T2D in socioeconomically deprived areas. Findings may also be transferable to other long-term conditions. Dissemination will be undertaken as a continuous process, supported by the stakeholder group. Tailored outputs will target the following audiences: (1) service providers and commissioners; (2) people at high risk of T2D and community stakeholders; and (3) policy and strategic decision makers.

PROSPERO REGISTRATION NUMBER

CRD42020196259.

Preventive Metformin Monotherapy Medication Prescription, Redemption and Socioeconomic Status in Hungary in 2018-2019: A Cross-Sectional Study

This study was designed to characterize the spatial distribution of metformin medication used as first-line monotherapy for prevention of T2DM in relationship with the socioeconomic status (level of deprivation) and T2DM mortality at district level in a nationwide cross-sectional ecological study for the first time in a European country, Hungary. Risk analysis was used to estimate the relationships between socioeconomic status, characterized by tertiles of deprivation index, and mortality caused by diabetes, and metformin medication (both prescription and redemption) for the years of 2018 and 2019 at the district level. The spatial distribution of districts with a higher relative frequency of metformin prescriptions and redemptions showed a positive correlation with socio-economic deprivation. Significant association between the relatively high T2DM mortality and the highest level of deprivation could also be detected, but less-deprived regions with high T2DM mortality and low metformin utilization could also be identified. Although the statistical associations detected in this ecological study do not indicate a causal relationship, it is reasonable to suppose that the underuse of metformin medication may contribute to the unfavourable T2DM mortality in certain regions. Our findings underline the need for more effective preventive services including metformin medication to decrease T2DM morbidity and mortality burden.

Exercise as a complementary medicine intervention in type 2 diabetes mellitus: A systematic review with narrative and qualitative synthesis of evidence

BACKGROUND AND AIMS

Type 2 diabetes mellitus (T2DM) is a rapidly growing public health issue. This systematic review aimed to narrate and qualitatively synthesize evidence and recommendations of physical activity/exercise for patients with T2DM.

METHODS

The databases Medline through Pubmed, Cochrane, and Scopus were systematically searched from inception to February 08, 2020 using MeSH terms related to "diabetes mellitus" and "physical activity/exercise". Studies were included if they reported on the roles of physical activity/exercise in managing patients with T2DM or effects of physical activity/exercise on glycemic control. Documents identified through the search were analyzed and evidence and recommendations were synthesized qualitatively.

RESULTS

Data were extracted from 16 original articles and 11 systematic reviews with meta-analyses. A qualitative summary of evidence included general items (n = 6) and recommendations for physical activity/exercise (n = 12). Physical activity/exercise can reduce incidence of T2DM, hyperinsulinemia, fasting plasma/blood glucose, HbA1c, body fats, cholesterol, blood pressure, heart rate, cardiovascular risk, and dosage of antidiabetic medications. Physical activity/exercise can improve sensitivity to insulin, muscle strength, oxygen consumption, aerobic capacity, and mental health of patients with T2DM.

CONCLUSION

Despite the increasing interest in incorporating physical activity/exercise in the management of T2DM and improving healthcare delivery, there are still limited clear instructions and guidelines for both the patient and the healthcare provider.

Risk perception of developing diabetes: A concept analysis

BACKGROUND

Cognitive risk perception has been linked to health behavior needed to reduce the risk of developing type 2 diabetes. The concept of risk perception of developing diabetes needed review due to: (a) frequent lack of congruency between perceived and actual risk of developing diabetes, and (b) inconsistent measures for calculating perceived diabetes risk.

DESIGN

The concept analysis was conducted using the Walker and Avant approach.

DATA SOURCES

Dictionary definitions, thesaurus synonyms and antonyms, theoretical sources, and seminal works related generally to risk perception were reviewed. Database searches for studies conducted in the United States measuring perceived risk of developing diabetes, were conducted in PubMed, Embase, and CINAHL; resulting in the selection and review of 23 research articles.

RESULTS

The identified dimensions of perceived diabetes risk were: perceived likelihood, personal risk, general risk, cognitive, emotional, comparative risk, and unrealistic optimism. Some antecedents of perceived diabetes risk were motivational factor, individual difference, contextual factor, cognitive factor, and affective factor. A consequence of perceived diabetes risk was health-promoting behaviors.

CONCLUSIONS

This concept analysis increases clarity of a multidimensional concept, providing a basis for validity for measurements. Consideration of antecedents for perceived diabetes risk will be important as related to diabetes prevention efforts.

Response to diagnosis of pre-diabetes in socioeconomically deprived areas: a qualitative study

Background

Diabetes prevention is a key priority for the NHS, with a particular focus on populations at highest risk. The NHS Diabetes Prevention Programme (NHS DPP) has been introduced, offering a course of dietary and lifestyle education to individuals with pre-diabetes. However, concerns about the NHS DPP include: (1) the possible unintended consequences of labelling more people with a ‘pre-condition’; (2) the possibility of worsening health inequalities as people in socioeconomically deprived areas tend to access behaviour-change programmes less readily; (3) the appropriateness of an intervention focused on individuals versus population-wide public health policy interventions.

Aim

To explore the experience of diagnosis of pre-diabetes, and understand the barriers and facilitators to uptake of the NHS DPP for people living in socioeconomically deprived areas.

Design & setting

A qualitative study was undertaken. Participants with pre-diabetes were recruited from practices serving socioeconomically deprived areas of Sheffield, UK.

Method

Semi-structured interviews were conducted and continued until data saturation (23 participants). Thematic analysis of data was undertaken.

Results

Both healthcare context and an individual’s personal and community context shaped response to diagnosis and likelihood of engaging with the NHS DPP. Patient activation was a useful concept in understanding response. Whether or not people participated in the NHS DPP, being diagnosed with pre-diabetes tended to provoke some degree of dietary change and did not cause significant anxiety for most. However, there were multiple barriers to engaging with the NHS DPP for this patient group.

Conclusion

Diagnosing pre-diabetes can provoke an individual positive response, but the sociocultural environment often limits an individual’s ability to engage with the NHS DPP or make lifestyle change.

Exploring patient perspectives of prediabetes and diabetes severity: a qualitative study

Objective: This qualitative study sought to identify and describe patients' variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis. Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients' perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients. Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients' beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons. Conclusions: Beliefs about severity are influenced by patients' fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions.